Doctors’ Obesity Bias (2016)

16-34 Doctors’ Obesity Bias

Reed Pence: Two-thirds of Americans are either overweight or obese. That’s a rate that’s doubled over the last 35 years. Today, the average American is about 25 pounds heavier than the average person in 1960. Yet studies show that most of us have persistently negative attitudes about people just like us who carry extra weight.

Dr. Rebecca Puhl:  Some might expect the bias to have improved over time because rates of obesity have increased. And so we might expect societal tolerance to improve, but in fact we’re actually seeing that bias has worsened.

Pence: That’s Dr. Rebecca Puhl, professor of human development and family studies at the University of Connecticut and deputy director of the Rudd Center for Food Policy and Obesity.

Puhl:  We’ve done some national studies following people over a decade, and we see that reports of weight discrimination are increasing. We also see evidence of this in other types of experimental studies that look at public attitudes towards people that have obesity and compare those to the same kinds of studies that were done 40-50 years ago and we see that attitudes are worse.

Pence: Puhl says obesity bias is based on a persistent misconception held by the thin and obese alike… that a person’s weight is entirely their own responsibility. So they can be blamed if they’re overweight.

Puhl:  Because these kinds of messages aren’t challenged in our society, people who are struggling with weight sometimes internalize those types of messages and blame themselves for the stigma that they confront. Another reason is because if we look at our diet mentality that we have in our country, this reinforces the idea that body weight is temporary, is infinitely malleable, that a person can have whatever kind of body they want if they just work hard enough and lose weight.

Pence: You’d think that doctors would know that’s not true… that they’d know the science showing that weight is complicated and governed by a whole host of factors. Yet studies show that doctors mirror the rest of society.

Puhl:  There is so much weight bias in our society that healthcare providers are really not immune to that societal bias. What we’ve seen in a number of studies is that weight bias is often expressed by healthcare providers toward their patients who have obesity, and that the level or prevalence of weight bias among physicians is pretty much the same as what we see in the general population. In some cases, we see that this bias has worsened over time especially among individuals who are working in the obesity field. So this is a real problem. For example, the kinds of stereotypes that we often see present or expressed among healthcare providers are views that their patients with obesity are lazy, lacking in discipline, non-compliant with treatment recommendations, or just not motivated to lose weight, and often that they are personally blamed for their weight. So those kinds of attitudes really underscore the fact that healthcare professionals are not immune to the broader negative societal attitudes that we see.

Dr. David Katz: The prevailing biases in our culture which have long been to associate obesity with things like laziness and gluttony and frankly that’s just false, I think that tends to be shared with physicians just because physicians are part of our culture, so if we’ve got prevailing biases they tend to affect everybody. But if they’re compounded in medical practice, it’s the frustration of, I think what we can only call impotence, the feeling like you’re supposed to be able to help, and you’re not really very good at helping, and nobody likes those kinds of impasses and eventually that frustration takes over and we tend to behave badly.

Pence: In fact, Dr. David Katz sometimes apologizes to patients on behalf of the medical profession. Katz is director of the Yale-Griffin Prevention Research Center at Yale University and founder of the True Health Initiative.

Katz: It’s important to look around and recognize, gee this is affecting not just a lot of people, but a massive majority of people in modern culture and not just in the U.S. but around the world. This has to be something bigger than individuals’ will power or personal responsibility. Those things matter, but pandemic obesity in the modern world can’t be about that. We have no evidence to suggest that the modern generation of adults, to say nothing of children, has less native personal responsibility than every prior generation. It’s not even plausible that seven year olds are suddenly less personally responsible these days. And yet we have massively higher rates of obesity in adults and children alike.

Pence: Katz says a doctor’s obesity bias is likely to show up in one of two ways.

Katz: One would be to ignore the issue all together. The problem with that is that obesity really is a canary in the coalmine of chronic disease. You gain the weight before you become insulin resistant and develop type 2 diabetes. You gain the weight before excess adipose tissue causes systemic inflammation, which contributes to the risk of heart disease, cancer, stroke, dementia, every bad thing, so it’s an early warning indicator on the patient’s dash board and we want doctors reacting to it. But if you’re biased against it, if you feel impotent to do anything about it, if you feel it’s the patient’s business to take care of their weight, if you don’t view it as a legitimate medical concern, you just don’t talk about it at all. I’ve seen that happen many times over the years.

Pence: Katz says the alternative may be even worse, when a doctor wags an admonishing finger and lectures the patient.

Katz: Don’t you realize that being so heavy is bad for you? You should do something about it, as if it were that easy. And of course we don’t do that with hypertension and we don’t do that with coronary disease…”Don’t you realize that coronary disease is bad for you? Just clean out your coronary arteries for crying out loud.” We don’t do that. We accept that many chronic diseases have major lifestyle factors affecting them, if not directly responsible for them, but we don’t blame patients for them. But with obesity, we tend to. So when you wag that admonishing finger and blame the victim, you pretty much never help anybody lose weight, but you do make them feel about an inch tall.

Pence: Puhl’s studies show that for men, the difference in how they’re treated doesn’t come until they’re about 75 pounds overweight. But for women, doctors’ obesity bias kicks in much sooner — when they’re only about 13 pounds overweight. So millions of women know what’s coming when they make an appointment.

Kathy Kater: They know when they go to see the doctor that they are a larger fatter person, they know that the doctor knows that, the patient makes some assumptions in some ways that the doctor will have a bias against that. The doctor knows that the patient knows. It ends up making a huge, awkward communication right almost from the get go.

Pence: That’s Kathy Kater, a psychotherapist in St. Paul, Minnesota, who specializes in body image, eating and weight issues, including weight stigma.

Kater: So many of my patients have become really very phobic about having to go to the doctor because, well, I’ll just tell you a little story…A patient I was working with just a while ago needed to get a new physician and, actually the reason that she had for going was that she had a painful wart on her foot, so she thought she would use that as a way to introduce herself to the doctor and see if this was someone she wanted to work with. He did talk to her about the wart, but before the session was over, before the visit was over, he said to her, “And next time you come in I’d like to talk to you about weight loss surgery.”

Pence: Puhl says there haven’t been studies on the extent to which doctors blame every malady on obesity, and don’t bother to look beyond that. But you can’t miss the stories that even a sore throat might be blamed on a person’s weight. Puhl says many people seem to think fat shaming has value. Perhaps especially when a doctor’s doing it.

Puhl:  There seems to be this ongoing public perception that maybe weight bias or stigma is not such a bad thing. Maybe it will motivate or incentivize people to lose weight. When we look at the research on this we see that exactly the opposite is true, that being a target of weight stigma or bullying or discrimination leads to a range of negative emotional and physical health consequences. So we see that this increases risk of things like depression and anxiety, suicidal thinking, but we also see that it leads to a range of unhealthy behaviors like increasing calories intake, disordered eating, binge eating, avoidance of physical activity. There are now longitudinal studies showing that over time people who are discriminated against because of their weight actually have an increased likelihood of obesity and weight gain over time, and we also see that this leads to heightened physiological stress.

Kater: Some people kind of actually believe that shaming someone, and I don’t think that doctors intentionally mean to shame someone, but that is the end result, that’s simply not an effective motivator, and in fact it leads people to feel like, well, why should I take care of myself? I’m really not a very good person anyway, and my doctor already assumes that I’m not doing what I should be doing.

Pence: Studies show that there are medical consequences, as well.

Puhl:  Patients who perceive that they have been stigmatized about their weight by a doctor have less trust in that doctor. They tend to have impaired treatment outcome. For example, they might not lose as much weight if they’re trying to lose weight. The are more likely to avoid future healthcare services, like preventative healthcare services. They are more likely to avoid future medical appointments. And we also see from the provider side evidence that doctors may actually spend less time in appointments with patients who have obesity compared to thinner patients. That they provide less health education. They don’t tend to build as much emotional rapport and they report having less desire to help these patients compared to thinner patients.      

Pence: Katz says millions of patients simply quit going to the doctor rather than allow themselves to be judged visit after visit. Sometimes, he says, it has tragic consequences, as it did with his own grandmother.

Katz: My grandmother was obese throughout her adult life. The doctors that she went to back in those days wagged that admonishing finger every time and everything that was ever bothering her about her health, all she ever heard was lose weight, which obviously she couldn’t do. If she could have lost the weight and kept it off she would have done that. She just stopped going to the doctor and tragically in her case she developed breast cancer, but wasn’t being screened. When she first presented with it, it was very far advanced and she died very young of metastatic breast cancer that could have been caught early and treated if she’d been going to doctors routinely and specifically, because of the harsh treatment of her weight, she didn’t go.

Pence: So what can medicine do to break the cycle? Katz and Puhl say it has to start in medical school by teaching would-be doctors to be more aware of personal attitudes and biases, and that the causes of obesity are a lot more complex than mere personal responsibility. Kater says doctors also need to learn to focus less on weight alone.

Kater: Focus on the behaviors that enhance health regardless of a person’s size and shape. So it’s really a model that turns attention away from the number on a scale or your BMI and instead says, well, bodies are born to be diverse – some people are, no matter how they take care of themselves will probably always be thinner people. Some people no matter how they take care of themselves are always going to be larger fatter people. So the goal really is to encourage positive behaviors.

Pence: But Katz says all of those changes would amount to swimming upstream if our culture doesn’t change.

Katz: Maybe we have the expectation that physicians are going to come in and fix this. But our greater culture is actively propagating obesity, right? America runs on Dunkin’, we market multicolored marshmallows as part of a complete breakfast; McDonalds and Coca-Cola are the sponsors of the Olympic Games and the TV coverage of it, so just throughout our culture there is massive propagation of confusion about what a healthy diet is, about what it’s okay to eat, about the idea that you can drink all the Coca-Cola you want, don’t worry you’ll burn it all off if you go tiptoeing through the tulips. So, our culture conspires to create an obesity epidemic, and then people suffer the metabolic consequences, show up at the physician’s office, and we seem to think that physicians should fix it. I disagree.

Pence: Kater says one more factor will be important — ending the reverse of obesity bias, what she calls “thin privilege,” the automatic assumption that thin people make good lifestyle decisions. Our body weight is much more complicated than that. If being thin were so easy, two thirds of us wouldn’t be losing the battle.

You can find out more about all of our guests on our website, radiohealthjournal.net.

I’m Reed Pence.